Operational methods - Pharmaceutical Cures for Cancer

Pharmaceutical Cures for Cancer

6.2 Operational methods

Diseases which Medicines cure not, the Knife cureth; what the Knife cures not, Fire cureth; what the Fire cures not, they are to be esteemed incurable. ³²

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130 Constructions of Cancer in Early Modern England

Descriptions of what drove patients toward surgery usually foregrounded individual patients’ suffering. When the decision was made, however, and the patient came under the knife, the emphasis of surgical texts changed drastically. As in this discussion of ‘Knife’ and ‘Fire’, by the German medical practitioner Johannes Scultetus, medical textbooks and casebooks shifted their focus from patients to bodies, and from bodies to tumours. This new perspective was centred on ‘extirpating what is super-fluous’, and there were diverse methods by which surgeons could do just that. ³³ Some cancer operations were relatively minor, while others posed a serious risk to the patient’s life. Some were the work of minutes, while others took days to complete, and they could be undertaken on parts as diverse as the eyes, breasts, face, legs, and scrotum. ³⁴ This section identi-fies three main operations which constituted the vast majority of cancer surgeries, and which each showed relative homogeneity across the early modern period and the diverse locations in which they were performed.

These paradigmatic cancer operations – ordered here in terms of their increasing invasiveness and dangerousness – were simple lumpectomies, facial surgeries, and mastectomies.

For any operation, certain preparations had to be made and precautions taken before the patient came under the knife. As Wiseman observed, operating in the spring or autumn was preferable, though not always possible. ³⁵ In many cases, surgery represented the last resort in a course of treatment, so it was likely that the patient would already have been eating a prescribed diet and perhaps taking medicines aimed at redu-cing the tumour and strengthening the body. Where mitigating pain was concerned, Kaartinen argues that eighteenth-century surgeons often administered opiates and alcohol before a procedure. Although they showed concern for patients’ pain, however, most accounts of cancer surgery prior to 1720 make no reference to any such ministrations. This might have been because surgeons were aware of the possible risks of overdose with opiates in particular: as I shall discuss, records of palliative care show that medical practitioners were happy to prescribe laudanum to patients who were clearly dying, often to help them sleep, but they were conscious of the medicine’s potentially lethal side-effects. In addition, it was often necessary that the patient remain conscious so that the opera-tors could gauge his or her physical state. Sudden sensitivity to the knife might indicate that a surgeon had reached the bottom of a necrotic ulcer and touched living flesh; conversely, slipping into unconsciousness was a worrying sign of blood loss as well as a natural reaction to intense agony.

Tumours which appeared on the face, arms and legs often merited relatively minor surgeries (insomuch as any early modern surgery was

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‘minor’) which were designed to bring the malady to a swift conclusion while minimising its physiological and social impact on the patient.

As Alexander Read pointed out for ‘apostems’ (undifferentiated, gener-ally benign, lumps), surgery might be preferable to some medicines, particularly caustics, in such cases: ‘First, if Apostems be in the Face, to avoid the filthiness of the Scar, after the Curation. Secondly, in small Tumors: for so they will be the sooner whole’. ³⁶ Philip K. Wilson and Olivia Weisser separately note ‘the stigma of a marked body’: namely, that marks or moles on the face were often taken as signs of bad luck, or worse, symptoms of venereal disease. ³⁷ Patients might thus have been tempted to undergo this procedure even where tumours appeared slow growing or benign. Worried sufferers may also have been fearfully aware of cases in which facial tumours ulcerated and ‘ate’ through the cheeks, nostrils or eyelid.

In the best cases, excision of small tumours could provide a quick, if painful, resolution to the problem. Wiseman, for example, cited the example of ‘A Man of about fifty years of age ... with a hard unequall Tumour, of the bigness of a large Wall-nut, between the Coronal and Sagittal Suture’. ³⁸ This tumour, Wiseman recalled, ‘was at that time crusted over with a Scab, and seemed to be a milder sort of Cancer’. ³⁹ Wiseman decided to operate:

Therefore providing Dressings ready, I made an Incision round it to the Scull; then raised it off with a Spatula , and permitting the bloud to flow a while, dressed it up with Astringents. The third day after I took off Dressings, and saw the Lips of the Wound well disposed, and the Cranium uncorrupted. I rasped it till the bloud appeared under it, then dressed up the Wound with Digestives ... and after Digestion incarned and cicatrized it with as little difficulty, and dismissed him cured. ⁴⁰ Several factors contributed to this operation’s success. The tumour was, as Wiseman noted, ‘resting upon the Cranium ’, a hard base from which it could easily be separated. The lump was relatively small, and the patient was acquiescent to Wiseman’s method, allowing him to apply medi-cines and cauterize the wound over several days. Wiseman’s description, however, was atypical of the kinds of operation most frequently found in medical textbooks. Whether because they were felt not to merit recounting, or because they were rarely carried out, straightforward excisions of sub-dermal tumours were the exception rather than the rule. Most descriptions of cancer surgery on the face and limbs recorded rather more complicated procedures, often with less positive outcomes.

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Despite the distinctive symptoms identified by various medical prac-titioners as signalling cancer, it is clear that many patients, particu-larly those travelling from the countryside to seek medical advice in the city, did not identify their tumours as cancerous until they reached an advanced stage. Furthermore, they were understandably reluctant to consent to surgery until it became clear that there was no other option.

This state of affairs may explain why most of the facial cancer surgeries described in medical texts (and among cancer operations, facial surgeries far outstripped everything but mastectomies) tended to be lengthy, often complex affairs. Surgeons described operations for tumours which had spread over the face, often involving the gums, nasal cavities, eyelids and even the eye itself. For instance, in another of his many examples of the difficulties of cancer surgery, Wiseman recounted the case of a

‘military Captain’ whose initially minor mouth cancer had spread to include the salivary glands, both ‘ Maxilla ’ (bones of the upper palate), the lower lip, the gums (causing some teeth to fall out) and some glands under the jaw. ⁴¹ On consulting Wiseman, the patient was informed that his tumour was cancerous, and resolved to have it removed by Wiseman with the help of fellow practitioners Thomas Cox, Walter Needham and

‘Mr. Gosling ’. ⁴² Wiseman commenced by pulling out the patient’s loose teeth, then set to work with a series of ‘actual’ cauteries or hot irons:

[H]aving his Head held firm, and his lower Lip defended, I passed in a plain Chisel cautery under the Fungus , as low as I could, to avoid scorching of the Lip, and thrust it forward towards the Tongue, by which I brought off that Fungus and the rotten Alveoli at twice or thrice repeating the Cautery; then with Bolt-cauteries dried the Basis to a crust. After with a Scoop-cautery I made a thrust at the Fungus over-spreading the left Jaw, and made separation of that, and what was rotten of the Alveoli: then with Olive and Bolt-cauteries I dried that as well as he would permit. ⁴³

This patient’s surgery was far lengthier and more dangerous than the simple excision with which Wiseman had removed the cranial tumour.

As the limits of the patient’s ‘permission’ indicate, it must also have been excruciatingly painful. Wiseman and his contemporaries recorded more of these kinds of operations – lengthy removals including the use of both knife and cautery – than they did simple lumpectomies, despite the fact that these complex procedures were often unsuccessful. The unfortunate Captain, for example, endured several more days of similar treatment, but eventually died when the tumour spread throughout his

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mouth and into the larynx, an outcome which Wiseman attributed in part to reluctance to allow him ‘to keep down the Fungus afterwards as it arose’ by use of further cautery. ⁴⁴

Wiseman seems to have been particularly innovative in his cancer surgeries, and assiduous about recording the most interesting examples.

Operations for facial tumours, however, were recorded throughout the early modern period. For example, the 1634 collected Workes of Ambroise Paré, which had first appeared in French in 1575, recounted a ‘new and never formerly tried, or written of way’ by which the author had removed a facial tumour in a 50 year-old man. ⁴⁵ ‘The way is this’, instructed Paré:

The Cancer must be thrust through the lips on both sides, above and below with a needle and threed, that so you may rule and governe the Cancer with your left hand, by the benefit of the threed (least any portion thereof should scape the instrument in cutting) and then with your Sizers in the right hand, you cut it off all at once, yet it must be so done, that some substance of the inner ... lippe, which is next to the teeth, may remaine, (if so be that the Cancer be not growne quite through) which may serve as it were for a foundation to generate flesh to fill up the hollownesse againe. Then when it hath bled sufficiently, the sides & brinkes of the wound must be scarified on the right and left sides, within, and without, with somewhat a deepe scarification, that so ... we may have the flesh more pliant and tractable to the needle and threed. The residue of the cure must be performed just after the same manner as we use in hare-lips’. ⁴⁶ Omitting the hot irons later employed by Wiseman, Paré’s operation offered the opportunity to ‘rule and governe’ this most ungovernable disease. Perhaps tellingly, however, the success of his venture was unre-corded: Paré advanced the method as one by which cancers might be cured without cautery and the associated scarring, but gave no details as to the survival or otherwise of his patient in this case. Despite the uncer-tain outcome of Wiseman and Paré’s procedures, versions of the same were employed throughout the late sixteenth, seventeenth and early eighteenth centuries. ⁴⁷

While a number of medical practitioners seem to have been aware of, and occasionally practised, operations for facial tumours, in general cancer surgery reflected the disease’s status as paradigmatically afflicting the female breast. Despite its invasiveness, the mastectomy operation was by far the most prominent in medical textbooks, casebooks and

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134 Constructions of Cancer in Early Modern England

advertisements. Most mastectomies followed a similar template: the pulling away of the breast from the body, followed by the removal of the whole breast with a sharp implement. William Beckett’s 1711 New Discoveries Relating to the Cure of Cancers relates the procedure in brief but excruciating terms:

Let the Patient be placed in a clear Light, and held steady; then take hold of the Breast with one hand, and pull it to you; and, with the other, nimbly make Incision, and cut it off as close to the Ribs as possible, that no Parts of it remain behind. But if any cancerous Gland should remain, be sure to have actual Cauteries of different sizes, ready hot by you, to consume it, and to stop the Bleeding; or other-wise apply, for restraining the Hemorrhage, Dorsels dipp’d in scalding hot Ol. Terebinth [turpentine oil] ... then with good Boulstring and Rolling, conveniently place the Patient in Bed, and at night give her an anodine Draught , then the second or third Day open it, digest, deterge, incarn and siccatrize. ⁴⁸

Beckett’s procedure contained several variables which medical practi-tioners altered according to their own preferences. He provided no instruction, for example, as to what one should use to ‘nimbly make Incision’. Most operators favoured a knife or razor, but the Dutch surgeon Paul Barbette noted that some surgeons used needles or hooks and a ‘string’. ⁴⁹ In his 1710 A Course of Chirurgical Operations , Dionis suggested one used both, helpfully supplying a diagram of his preferred equipment (Figure 6.3). ⁵⁰ ‘The Chirurgeon’, instructed Dionis, ‘with Ink traces out the whole Circumference, which is the place where the Incision is to be made’:

[T]hen running the crooked Needle D, across the Body of the Tumour;

it is threaded with the String E, whose two ends are tied, and with which he makes a Noose which serves to sustain the Tumour, and in drawing it to separate it from the Ribs ... then with Razor F, or a large flat Knife G ... the Chirurgeon cuts at the marked Place, and takes off the whole Body of the breast in a short time. ⁵¹

It seems – though Dionis’s explanation is unclear – that the string was passed through the base of the breast using the needle (as shown in Figure 6.4, from Scultetus’s The Chyrurgeon’s Store-House ). This served to partially separate the breast from the underlying muscle so that it was more stable and could more easily be excised. Kaartinen argues that the

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Figure 6.3 Pierre Dionis, A Course of Chirurgical Operations, Demonstrated in the Royal Garden at Paris (p. 247), 1710. Copyright of the University of Manchester.

This image is open access under a CC-BY NC-SA 4.0 licence.

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136 Constructions of Cancer in Early Modern England

Figure 6.4 Johannes Scultetus, ‘Breast cancer operation’, from Het vermeerderde wapenhuis der heel-musters , 1748. Courtesy of Wellcome Library, London. This image is open access under a CC-BY 4.0 licence.

needle and cord technique was ‘in vogue’ in the late seventeenth and early eighteenth century, after which it gradually disappeared. ⁵² In the sources I have examined, however, it seems to have been uncommon.

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There were, of course, exceptions to this rule: for example, a surgeon at Saint Bartholomew’s hospital, Joseph Binns, took the string method to an extreme. Tying a string around the breast on the morning of 9 August 1648, he ‘tied it harder’ over the next 13 days until on the 22nd, ‘the lower string was through the bigness of a finger, the upper one near to an inch’ and he ‘with string cut [the whole breast] off in the ligature’. ⁵³ Predictably, however, the patient died a week later: the absence of this procedure from other contemporary texts gives the impression that Binns either misunderstood instructions such as those given by Scultetus, or tried this method as an ill-fated experiment.

In a ‘typical’ mastectomy, therefore, the surgeon would probably use a knife to cut away the breast tissue. In all likelihood, he would have removed virtually the entire breast down to the chest wall. Dionis described a lumpectomy operation to be used when the cancer was small, palpable and movable, but he was in the minority. ⁵⁴ Conversely, Beckett recalled observing an operation in which ‘a Part of that [pectoral]

Muscle was cut away, and the cartilages of Two of the Ribs laid bare, and the patient happen’d to be cur’d’. ⁵⁵ This too was uncommon, presum-ably because it increased mortality rates even further. ⁵⁶ While they were wary of removing too much flesh, surgeons remained mindful of the disease’s characteristic malignancy, and repeatedly stressed the import-ance of removing every trace of the cimport-ancer. ‘[I]t must be all taken away’, stressed Bonet:

A Canker once cut doth often come again, 1. When all was not cut out, through timorousness, either in the Operatour, or in the Patient.

2. Because the Arteries that emit this vitious bloud, by reason the less Arteries are cut away from the part affected, must contain more bloud than before, and therefore when they are open, will discharge that bloud upon some other part, whence comes a new Canker. 3.

Because there is so much malignity latent in the Body, that a Canker will always grow afresh. ⁵⁷

Though the operator could do little about cancer ‘latent in the body’, he could, it was believed, minimise the risk of recurrence by pressing the bad blood out of the nearby veins and making sure to excise every scrap of cancer either with the knife or cautery. Precisely what means were used to complete the operation and stop the wound from bleeding was mostly a matter of individual choice, sometimes influenced by the constitution and temperament of the patient. Dionis, for example, reported that he had stopped using hot cauteries because they ‘make the

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Patient tremble’ and he could achieve the same result by skilful use of the knife, followed by ‘Pledgets’ (material pads) and ‘astringent powders’

to stop the bleeding. ⁵⁸ In line with contemporary wisdom that closing a wound was dangerous, surgeons generally did not stitch the site of mastectomies or other substantial cancer operations until later in the eighteenth century. ⁵⁹

Post-operation, the patient was at high risk of infection, as well as remaining in considerable pain. Occasionally, surgeons would return to treat the wound with hot cauteries again. ⁶⁰ Whether because this course was intolerable to the patient, however, or because it was ineffective, such extended treatment was fairly uncommon. ⁶¹ Instead, surgical texts often recorded either the authors or their colleagues administering prescriptions with soothing and anti-inflammatory properties, as well as some potent analgesics. Wiseman, for example, prescribed one mast-ectomy patient a ‘Pearl-Julep’ ‘to refresh her fainting spirits’, and the next day she was given ‘distilled milk’, containing, among other ingre-dients, gentian, rose, agrimony, cinnamon and veronica. ⁶² In ‘extremity of pain’, he recorded, she was to be given a drink made with theriac, a concoction which usually contained opium and snake venom. ⁶³ In many cases, it appears that surgeons monitored their patients closely in the days after surgery, and remained aware of the potential for infec-tion or a recurrence of the cancer for months, even years. For their part, patients were advised to be constantly on the lookout for new tumours, and told they ‘must not discontinue the use of internal Remedies for some Years, lest a Fresh tumour should break out in some other Part, and

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